A 9-year-old boy was skateboarding with his friends over a hill when he entered a
major intersection and was hit by a car going approximately 40 mph down the
cross street. On arrival to the ED, HR 160 BP 110/70 RR 26, SpO2 96% RA. 
His primary survey was significant for thoraco-abdominal ecchymosis; secondary survey showed a GCS of 11 with agitation.  He was endotracheally intubated for declining clinical course and behavior control.

CT of his abdomen shows grade III liver laceration; initial hemoglobin is 9 g/dL.  On return from radiology, HR 170 BP 88/60.  He is started on a massive transfusion protocol in a 1:1:1 ratio (PRBCs:Plasma:Platelets); after 40 mL/kg of PRBCs, his repeat vital signs show HR 110 BP 100/80 with normal urine output and skin signs.  
 
While awaiting a bed in the intensive care unit, he develops a wide-complex
tachycardia with a palpable peripheral pulse:

What action should be taken immediately?

     A. Perform thoracotomy, cross-clamp aorta, open cardiac massage
     B. Membrane-stabilization therapy
     C. Re-initiate massive blood transfusion to optimize oxygenation
     D. Emergent hemodialysis
 

In the meantime, a quote – 
 
Every man prefers belief to the exercise of judgment.

– Lucius Annaeus Seneca, Roman Stoic philosopher (4 BC – AD 65)

…and…

Experts often possess more data than judgment.

– Colin Powell, retired US Army general (1937 - ) 

A 72-year-old woman with a history of COPD, hypertension, and chronic constipation
arrives to the ED after feeling weak and dizzy earlier today when standing from
a sitting position.  She denies preceding or subsequent chest pain; shortness of breath; nausea; head, back, or abdominal pain.  There is no history of trauma and she has had no recent changes to her medications.  On review of systems, over the past few months she has had generalized weakness and family reports her slow progression of having less energy, needing more time to get dressed, and becoming easily confused and fatigued.  They are concerned that they can no longer care for her at home.

On examination, our patient’s vital signs are: T 97.0 °F HR 66 BP 118/70 RR 12 SpO2 96% RA.  In general, she is slow to respond but attends well to questioning; her
voice is coarse, which her family attributes to her previous smoking history.  Her cardiovascular and pulmonary exams are unremarkable.  Total body check shows no evidence of trauma, infection, or toxidrome; her skin is dry and flaky, but with normal turgor.  Her electrocardiogram, chest x-ray, metabolic panel, and urinalysis are
all inconclusive.  She remains hemodynamically stable in the ED.

Which is the next BEST step in her management?

    A. Admit her for observation and likely placement
    B. Stop all medications and admit for medication washout
    C. Discharge home with follow up and likely placement as outpatient
    D. Admit for likely hormone replacement therapy


In the meantime, a quote – 

"Old age hath yet his honour and his toil." 

– Alfred Lord Tennyson (1809-1892)

A two-week-old baby boy is brought in by his mother for a “bump” on his head that
has recently become more apparent.  The child was born full term via normal spontaneous delivery without complication.  There has been no history of trauma, fever, or change in intake, output, or behavior.  The boy’s first well-child appointment is tomorrow morning, but an alarmed family member convinced the family to seek help tonight.

On examination, the child is well appearing with normal vital signs and an otherwise normal total body check.  The area of concern is shown below:

Which of the following is the BEST course of action?

    A. CBC, blood cultures, incision and drainage, admission to the hospital
    B. Tie base of lesion with silk suture, observe briefly, outpatient follow-up
    C. Watchful waiting and referral to primary medical doctor
    D. Obtain stat MRI


In the meantime, a quote – 
 
Festina lente.

[Make haste slowly.]

– Classical adage

A 27-year-old woman with no past medical history complains of one week of dizziness and palpitations, especially when she gets up quickly; she is now asymptomatic in the ED.  She states that she “gets this way from time to time”, and she is sure that it “must just be my stress”.  The woman is not taking any medications, and denies illicit substances, recent illness, or change in her diet.  Her vital signs and cardiovascular and neurologic examinations are normal, and she is not pregnant.

Her electrocardiogram shows a heart rate of 68, no evidence of pre-excitation, and no ST or T wave changes from a previous electrocardiogram done for the same complaint three months ago: QT interval 480 ms, corrected QT (QTc) 512 ms.

Which of the following would be the MOST helpful in establishing a diagnosis:

    A.    Serum potassium level
    B.    Serum magnesium level
    C.    Serum calcium level
    D.    Repeat electrocardiogram


In the meantime, a quote – 
 
“To each one of you the practice of medicine will be very much as you make it – to one a worry, a care, a perpetual annoyance; to another, a daily joy and life of as much happiness and usefulness as can well fall to the lot of man.”

–William Osler